Private Health Insurance Decision Reference 2022-0374

• Case Outcome: Rejected
• Reference: 2022-0374
• Date: 29 November 2022
• Year: 2022
• Subject Matter: Private Health Insurance
• Finantial Sector: Insurance
• Conducts Complained Of: Rejection of claim - waiting periods apply ,Claim handling delays or issues, Disagreement regarding Medical evidence submitted , Failure to process instructions in a timely manner

Decision Ref:

2022-0374

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Rejection of claim - waiting periods apply

Claim handling delays or issues

Failure to process instructions in a timely manner

Disagreement regarding Medical evidence

submitted

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint concerns a health insurance policy held by the Complainant and the

Provider’s decision to decline a claim made under that policy.

The Complainant’s Case

The Complainant submits that she took out her policy with the Provider in January 2018 and

that she injured her right arm on 30 March 2018, “while heavy lifting at work on a festival”.

She submits that she attended her GP regarding the injury on 2 June 2018 “with a small

amount of discomfort with a swollen vein in [her] right arm”. The Complainant states that

she was referred on to a surgeon who performed a procedure to remove the vein in

November 2018.

The Complainant states that she “checked with [the Provider] and they said the procedure

would be covered by [her] insurance]”. The Complainant states that in May 2020 the

Complainant received a letter from the Provider stating that the procedure would not now

be covered and that she owed almost €1,300 (one thousand three hundred Euro).

The Complainant says that when she spoke to the surgeon at the initial consultation, he

noted the date of the injury incorrectly as having occurred nine months earlier, rather than